2) She is a member of UKCPA Diabetes & Endocrinology committee @UKCPADiabetes & works across #diabetes, #endocrinology, & emergency/acute care in Secondary Care. She is currently involved in development of regional guidelines & education to support medicines optimisation for PLWD
— cardio-met (@cardiomet_CE) June 7, 2022
4) Claire is part of the @GoggleDocs family of experts.
— cardio-met (@cardiomet_CE) June 7, 2022
In true @GoggleDocs fashion, she’ll start with a couple of polls to set the scene… pic.twitter.com/Rn0HcJQPJP
5b) Answer: c – a third. A third of people with T2DM have CV disease
— cardio-met (@cardiomet_CE) June 7, 2022
🔓https://t.co/3gmIETEUwc
6b) Answer: c – 37% of adults with diabetes have been diagnosed with CKDhttps://t.co/WU5q8gsUJZ
— cardio-met (@cardiomet_CE) June 7, 2022
8) Let’s start with some cases to put this theory into practice. All cases are fictitious, any resemblance to real people is coincidental. Ready, steady, go… pic.twitter.com/nNUo00awMS
— cardio-met (@cardiomet_CE) June 7, 2022
10) Her medication history includes a basal-bolus #insulin regimen, #metformin, multiple antihypertensives.
— cardio-met (@cardiomet_CE) June 7, 2022
You see this person in clinic, and that day her vitals are BP, 162/90, P 68, Height 167 cm (5’6″), Weight 81 kg (178 lbs).
12) The answer is all of the above, as these are all interlinked. So how do we choose a priority? pic.twitter.com/rYu38nXhpj
— cardio-met (@cardiomet_CE) June 7, 2022
14a) Let’s take each of those options in turn:
— cardio-met (@cardiomet_CE) June 7, 2022
👉⬆️Thiazides: rarely effective for BP at higher doses, so perhaps not be a good option as the pt has no oedema
👉⬆️ #CCB: potentially a good option but will only improve #BP & none of the other priorities
15) #GLP-1 agonists & #SGLT2i‘s have shown proven benefit in #cardiovascular outcome trials (#CVOTs). Sulphonlyureas have not demonstrated this. Pioglitazone should be AVOIDED in people with HF as per MHRA/CHM alert (🔓https://t.co/zohVuaniuZ). pic.twitter.com/LiTskB6NLk
— cardio-met (@cardiomet_CE) June 7, 2022
17) @NICE NG28 recommends a #SGLT2 inhibitor with proven #CV benefit in anyone with chronic #HF or established #ASCVD.
— cardio-met (@cardiomet_CE) June 7, 2022
See 🔓https://t.co/JW4rfcrrxB pic.twitter.com/3wn4irgbCf
19) We need to:
— cardio-met (@cardiomet_CE) June 7, 2022
👉Assess #DKA risk
👉Address modifiable risk factors for DKA before starting a #flozin
This is because #SGLT2 inhibitors can cause euglycaemic #DKA so we have to ensure we start and use them appropriately and safely, as with any medication. pic.twitter.com/GcCkNKcYcd
21a) Let’s go in reverse here. How many carbohydrates is “low carbohydrate”? @NICEComms have helpfully specified – 20-50g/day of carbohydrate or less than 10% of a 2000kcal/day diet
— cardio-met (@cardiomet_CE) June 7, 2022
21c) Why do we worry about intercurrent illness with #SGLT2i? Risks of dehydration & DKA risk, so pts on SGLT2i’s should be advised to hold their SGLT2i temporarily & only restart 48 hours after symptoms have resolved #sickdayrules
— cardio-met (@cardiomet_CE) June 7, 2022
🔓https://t.co/fz2uWJo6OQ pic.twitter.com/sw0gnTboe7
23a) From this do you think a #SGLT2 inhibitor is safe in this person?
— cardio-met (@cardiomet_CE) June 7, 2022
24) We could check antibodies/C-peptide to confirm diabetes diagnosis. For information on diabetes tests check out: https://t.co/Y1jAalVKHa
— cardio-met (@cardiomet_CE) June 7, 2022
For this patient, we may need specialist input. pic.twitter.com/gcfyKfUmrf
26) Key Points from this case:
— cardio-met (@cardiomet_CE) June 7, 2022
🔑#SGLT2i‘s⬇️risk of CV death, #HHF, & HF sx so may be good agent for pts w/#T2D + #HF
🔑With #eGFR >45, SGLT2i’s also confer glycaemic benefit
🗝️Before starting SGLT2i, must✅DKA risk & discuss diet & sick day rules
🗝️ Care must be individualized
27b) 👉Prescribing Tool for SGLT2 inhibitors – https://t.co/qHNXUqlgYK pic.twitter.com/DROHpMRSBR
— cardio-met (@cardiomet_CE) June 7, 2022
28) Welcome back, it’s day TWO of #accredited #tweetorial on challenging case presentations for the management of patients with #cardiometabolic disease, #CaReMe #FOAMed. I am @claireyrivs and I work with the @GoggleDocs 🇬🇧
— cardio-met (@cardiomet_CE) June 8, 2022
30) Let’s drive straight in with another case! pic.twitter.com/TJAcMVeEY6
— cardio-met (@cardiomet_CE) June 8, 2022
32) What are our priorities for this person living with #diabetes? We might focus on
— cardio-met (@cardiomet_CE) June 8, 2022
👍BMI and weight management
👍HbA1c
👍👍Both of the above
Yes! Again, because the #cardiometabolic problems are interlinked, it's both!
34) So let’s take them one by one.
— cardio-met (@cardiomet_CE) June 8, 2022
👉DDP-4 inhibitors, or ‘gliptins’ – these might help with HbA1c control but are weight neutral, so let’s skip on those for this person. We can do better!
👉Pioglitazone can cause weight gain. So again it’s a NO from me!
36) First let’s look at the @NICEComms Guidance for intensification of therapy pic.twitter.com/OXzmb16K90
— cardio-met (@cardiomet_CE) June 8, 2022
38) He has a BMI of <35kg/m2. For this person with diabetes ‘weight loss would benefit other significant related comorbidities’ so he meets the NICE criteria for GLP-1 initiation.
— cardio-met (@cardiomet_CE) June 8, 2022
A quick reminder on how GLP-1 agonists work with this helpful diagram: pic.twitter.com/1CPZ40ppKL
40) So it’s important to think about weight and weight management alongside CV risk and as a part of the cardio, renal, metabolic triad #CaReMe
— cardio-met (@cardiomet_CE) June 8, 2022
Another question: Would this person qualify for having a GLP-1 agonist for obesity (as primary indication) rather than diabetes?
41b) For #dulaglutide, no . . . at least not yet, not on either side of the Atlantic. In the US, #semaglutide carries this label: indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients …
— cardio-met (@cardiomet_CE) June 8, 2022
42) In 🇬🇧, semaglutide has draft NICE guidance: 🔓https://t.co/To5ADqJrKq that is promising: pic.twitter.com/c7JQCQ6vUp
— cardio-met (@cardiomet_CE) June 8, 2022
43a) So under these new proposed criteria our patient in future would qualify for #semaglutide for weight management as part of a tier 3 service. This is based on evidence from the #STEP1 #RCT ➡️pts taking semaglutide lost on average, 12% more of their body wgt vs placebo.
— cardio-met (@cardiomet_CE) June 8, 2022
44) So, key points from this case:
— cardio-met (@cardiomet_CE) June 8, 2022
👉Weight management and diabetes and intrinsically linked
👉Both independently increase CV risk
👉GLP-1 agonists can be used for both diabetes and obesity but with different criteria and different brands
46) WELCOME BACK! I am @claireyrivs, I work with the @GoggleDocs, and it’s day THREE of our #accredited #tweetorial on challenging case presentations for the management of patients with #cardiometabolic disease, #CaReMe #FOAMed. Only one case to go for your pic.twitter.com/5n4pakRNYu
— cardio-met (@cardiomet_CE) June 9, 2022
48) Are you see some themes in these cases? Here our priorities are #BP, #HbA1c,➕slowing progression of CKD.
— cardio-met (@cardiomet_CE) June 9, 2022
What next steps could help with these clinical priorities?
a. ⬆️ACEi
b. Add another pharmaceutical agent
c. Adjust HbA1c🎯for individualised care
d. All of the above
50) Re #HbA1c – it’s important to not be guided by just a pure number. Individualised care (this pt is 81, remember) is at the heart of lots of guidelines, including NICE NG28, which includes the following patient decision aid:
— cardio-met (@cardiomet_CE) June 9, 2022
🔓https://t.co/5WiRsXRgow pic.twitter.com/BtHccS5q1n
52) So we have assessed frailty & established our pt is a fit older adult so no de-escalation is needed. So what do we do next?
— cardio-met (@cardiomet_CE) June 9, 2022
What drug could we add in to improve morbidity and mortality in #CKD and #T2D for this patient?
53b) This is being studied in EMPA-KIDNEY, the largest #SGLT2i trial in #CKD to date, studying efficacy & safety of empagliflozin in adults with CKD who are frequently seen in clinical practice but who have been under-represented in previous SGLT2i trials
— cardio-met (@cardiomet_CE) June 9, 2022
53c) EMPA-KIDNEY includes pts presenting with:
— cardio-met (@cardiomet_CE) June 9, 2022
👉Mildly- to severely ⬇️eGFR
👉Normal & ⬆️levels of albumin
👉+/- #diabetes
👉CKD attributable to a wide range of underlying causes.
The trial was stopped early after empagliflozin met pre-specified criteria for positive efficacy.
54) It's important to note this is different from the criteria in the NICE TA on #dapagliflozin in #CKD:
— cardio-met (@cardiomet_CE) June 9, 2022
🔓https://t.co/qjeEekwmPg pic.twitter.com/9mp17mOOrl
56) It's Important to note that in people with #CKD with an #eGFR <45ml/min/1.73m2, due to the mechanism of action of #SGLT2 inhibitors you are unlikely to see any notable glycaemic benefit.
— cardio-met (@cardiomet_CE) June 9, 2022
58) So when caring for people with #T2D and #cardiometabolic disease – remember:
— cardio-met (@cardiomet_CE) June 9, 2022
👍Think CVD
👍Think CKD
👍Think Obesity
And remember these are all linked to #T2D and there's more than one way to tackle each aspect!
60) And that's it–you have just earned 0.75h CE/#CME! Go to https://t.co/3sTIyvSfd0 to claim your credit & FOLLOW US for more education by #tweetorial all🆓all by EXPERT authors! I am @Claireyrivs of @GoggleDocs. Be sure to follow @ckd_ce also–especially my fellow #pharmacists! pic.twitter.com/cjFLbBFR2I
— cardio-met (@cardiomet_CE) June 9, 2022